Photo credit: Mike Bloem
PROGRAMMATIC GUIDANCE BRIEF ON
USE OF MICRONUTRIENT POWDERS
(MNP) FOR HOME FORTIFICATION
Prepared for HF-TAG implementation guidelines by:-
SGHI
2
PROGRAMMATIC GUIDANCE BRIEF ON USE OF MICRONUTRIENT POWDERS
(MNP) FOR HOME FORTIFICATION
Home fortification with MNP: purpose
and rationale
Home fortification is an innovation aimed at improving
the diet quality of nutritionally vulnerable groups, such
as young children. The term Micronutrient Powders
(MNP) refers to sachets containing dry powder with
micronutrients that can be added to any semi-solid
or solid food that is ready for consumption. Home
fortification with MNP aims to ensure that the diet,
i.e. complementary foods and breast milk combined,
meets the nutrient needs of young children1.
Home fortification is recommended where complementary foods do not provide enough essential nutrients.
This occurs where one or more of the following
apply:
a) dietary diversity is low (due to limited availability or affordability);
b) complementary foods prepared for the
small child have insufficient nutrient content
and density (for example, watery porridges
and foods with too low micronutrient content);
c) the bioavailability of micronutrients is poor
due to absorption inhibitors in the diet (fibre,
phytate, tannin), which is especially the case
in plant-source based meals.
These conditions are widespread in developing
countries where the diet is predominantly based on
staple foods, contains few animal-source and fortified
foods, and where tea consumption is common.
Home fortification increases micronutrient intake, which
leads to an improvement of micronutrient status, and
can therefore improve child health, including reduced
morbidity and mortality, improved growth, cognition,
appetite and other functional outcomes.
Other commodities for home fortification include
small-quantity Lipid-based Nutrient Supplements
(LNS)(<20 g/d, equivalent to ≤120 kcal/d) and other
complementary food supplements, such as soy-flour
with micronutrients, or malt powder with micronutrients,
essential amino acids and enzymes. These commodities
provide some other essential nutrients in addition
to micronutrients, such as macro minerals (calcium,
magnesium, potassium, phosphorus), essential fatty
acids and essential amino acids. As these products are
undergoing further development and as there is less
programmatic experience with their use, this document
focuses on MNP.
History of MNP development
MNP was originally developed to provide iron and other
nutrients required for treating nutritional anemia. This is
because iron and folic acid tablets cannot be swallowed
by young children and syrups had not been an effective
intervention, likely due to poor acceptability related
to a strong metallic taste, staining of teeth, bulky
packaging, and the potential for over-dosing. For this
reason, the efficacy of MNP was evaluated regarding its
impact on anemia and iron deficiency. The product was
formulated with three to five micronutrients, known
to be necessary for treating nutritional anemia. The
efficacy of MNP to treat anemia has been confirmed2,3.
This means that the MNP mixture of bioavailable
micronutrients was effective to treat anemia, and that
the mode of administration, i.e. a powder that is to be
mixed with food, was feasible.
While this research was ongoing, the potential of MNP
as a means of also preventing other micronutrient
deficiencies became apparent. Based on the knowledge that complementary feeding diets are often low in
many micronutrients, formulations containing a much
higher number of micronutrients, typically 15, were
developed for preventing micronutrient deficiencies in
general4.
The concept of using MNP for home, or point-of-use,
fortification to fill gaps in the diets of particularly
infants and young children, is now widely accepted.
This brief focuses on that purpose, i.e. using MNP to
prevent micronutrient deficiencies in general, whereas
the recent WHO guideline2 is based on studies that
focused on treating nutritional anemia.
Formulation of MNP
Currently, most countries use an MNP formulation
containing 15 micronutrients, which is designed to
provide one Recommended Nutrient Intake (RNI) of
each micronutrient per dose for children 6-59 months
3
old (see Table 1)
WFP and
Formulation
of5. MNP
UNICEF, as the main
procurers of MNP, almost exclusively procure the 15
micronutrient
However,
where
specific
Currently,
mostformulation.
countries use
an MNP
formulation
information 15
is micronutrients,
available that warrants
containing
which is adjusting
designed the
to
formulation,
this
could
be
done.
provide one Recommended Nutrient Intake (RNI)
of each micronutrient per dose for children 6-59
months
(see Table 1)5. WFP and UNICEF, as the
Targetold
groups
main procurers of MNP, almost exclusively procure
the
micronutrient
formulation.
where
The 15
target
group should
be those However,
who are at
risk
specific
information
is
available
that
warrants
of having an inadequate intake of micronutrients;
adjusting
the multiple
formulation,
this suggests
could bethat
done.
evidence from
countries
the
period of highest vulnerability is six to 23 months of age
when food
variety and quantity are limited. Children
Target
groups
24 to 59 months of age may also be at high risk of
inadequate
dietary should
intake be
of those
some who
nutrients.
The
target group
are atWhen
risk
home
fortification
is
being
introduced
in
a
population
of having an inadequate intake of micronutrients;
for a period
several countries
years, children
aged
evidence
fromofmultiple
suggests
that24-59
the
months
will
have
been
exposed
to
MNP
when
they
period of highest vulnerability is six to 23 months ofwere
age
6-23 months
of age.
Inquantity
that case,
the age
when
food variety
and
areprioritizing
limited. Children
range
of
6-23
months
may
be
a
good
choice.
However,
24 to 59 months of age may also be at high risk of
when the problem
of micronutrient
deficiencies
is
inadequate
dietary intake
of some nutrients.
When
widespread,
or
the
program
will
be
implemented
for
home fortification is being introduced in a population for
limited of
period
of time,
might be
better
to target
aa period
several
years,itchildren
aged
24-59
monthsa
wider
agebeen
range.
will
have
exposed to MNP when they were 6-23
months of age. In that case, prioritizing the age range
Another target group for MNP can be school children,
of 6-23 months may be a good choice. However, when
in particular those who receive school meals that have
the problem of micronutrient deficiencies is widespread,
limited micronutrient content because they consist
or the program will be implemented for a limited period
largely of staple foods, and protein and fat sources.
of time, it might be better to target a wider age range.
The micronutrient content of MNP for school feeding
should be age group appropriate. Preliminary
Another target group for MNP can be school children,
experience from WFP with adding MNP to school
in particular those who receive school meals that have
meals by kitchen staff is that it is easy to implement
limited micronutrient content because they consist
and acceptance by pupils and staff is good. Sachets of
largely of staple foods, and protein and fat sources. The
MNP used for school feeding typically contain 10 or 20
micronutrient
content
of MNP per
for school
should
dosages, which
are cheaper
dosagefeeding
compared
to
be
age group
appropriate.
Preliminary
experience
from
sachets
containing
one dose,
due to lower
packaging
WFP
costs.with adding MNP to school meals by kitchen
staff is that it is easy to implement and acceptance
by
pupils and staff
is good. Sachets
of MNP
used for
If increasing
the micronutrient
intake
of pregnant
school
feedingwomen
typically
contain 10this
or may
20 dosages,
and lactating
is desirable,
best be
which
are
cheaper
per
dosage
compared
to as
sachets
done in the form of a capsule, rather than
MNP,
containing
one
dose,
due
to
lower
packaging
costs.
because the relatively high dose of micronutrients
that is required is more likely to change the taste of
If
micronutrient
intake programming
of pregnant
theincreasing
food that itthe
is added
to, and limited
and
lactating
women
is
desirable,
this
may
best be
experience shows that women may prefer swallowing
done
in
the
form
of
a
capsule,
rather
than
as
MNP,
a capsule instead
adding something to their food.
because
high dose of micronutrients
The samethe
mayrelatively
apply to adolescents.
TABLE 1. RECOMMENDED NUTRIENT INTAKE (RNI) OF
TABLE
1. RECOMMENDED
NUTRIENT
INTAKE
(RNI) 6-59
OF
EACH MICRONUTRIENT
PER
DOSE FOR
CHILDREN
EACH
MICRONUTRIENT
PER DOSE FOR CHILDREN 6-59
MONTHS
OLD
MONTHSMicronutrients
OLD
Children (6-59 months)
Micronutrients
Children (6-59 months)
400
Vitamin A µg RE
Vitamin A µg RE
400
5
Vitamin D µg
Vitamin D µg
5
5
Vitamin E mg
Vitamin E mg
5
30
Vitamin C mg
Vitamin C mg
30
0.5
Thiamine (vitamin B1) mg
Thiamine (vitamin B1) mg
0.5
0.5
Riboflavin (vitamin B2) mg
Riboflavin (vitamin B2) mg
0.5
6
Niacin (vitamin B3) mg
Niacin (vitamin B3) mg
6
0.5
Vitamin B6 (pyridoxine) mg
Vitamin B6 (pyridoxine) mg
0.5
0.9
Vitamin B12 (cobalamine) µg
Vitamin B12 (cobalamine)
µg
0.9
6
150.0
Folate µg
Folate µg6
150.0
10.0
Iron mg
Iron mg
10.0
Zinc mg
4.1
Zinc mg
4.1
Copper mg
0.56
Copper mg
0.56
17.0
Selenium µg
Selenium µg
17.0
Iodine µg
90.0
Iodine µg
90.0
that is required is more likely to change the taste of
the
food that itand
is added
to, and of
limited
programming
Frequency
duration
taking
MNP
experience shows that women may prefer
swallowing
capsule
instead
of adding
something
In principle, athe
frequency
and duration
of using
MNP
to
theirbefood.
may apply
to adolescents.
should
suchThe
that same
it contributes
enough
of required
micronutrients so that the combination of the diet and
the MNP meetsand
the RNI
(i.e. theof
daily
recommended
Frequency
duration
taking
MNP
nutrient intake) for all micronutrients. When the
sachets
contain
one RNIand
forduration
each micronutrient,
In
principle,
the frequency
of using MNP
giving
90
sachets
for
a
six
month
periodof(providing
should be such that it contributes enough
required
on average 15 per month, i.e. 3-4 per week) would
micronutrients so that the combination of the diet and
result in an average dose of 50% of the RNI/d, 60
the MNP meets the RNI (i.e. the daily recommended
sachets for a six month period (10 per month, i.e. 2-3
nutrient intake) for all micronutrients. When the
per week) would be equivalent to 33% of the RNI/d,
sachets contain one RNI for each micronutrient,
and 120 sachets for a six month period (20 per month,
giving 90 sachets for a six month period (providing
i.e. 4-5 per week) would provide 67% of RNI/d.
on average 15 per month, i.e. 3-4 per week) would
result in an average dose of 50% of the RNI/d, 60
It is important to keep in mind that, for some
sachets for a six month period (10 per month, i.e. 2-3
micronutrients, the typical diet may contain 80%
per week) would be equivalent to 33% of the RNI/d,
of the RNI, whereas for others, it may only contain
and 120 sachets for a six month period (20 per month,
20-40%. In particular, the intake of vitamins and
i.e.
4-5 that
per are
week)
provide
67%source
of RNI/d.
minerals
mostwould
abundant
in animal
foods
4
PROGRAMMATIC GUIDANCE BRIEF ON USE OF MICRONUTRIENT POWDERS
(MNP) FOR HOME FORTIFICATION
(vitamin B6, vitamin B12, zinc, iron) may be relatively
low when these foods are consumed infrequently and
in small amounts. The RNI has also been established
for normal, healthy children, whereas children with
micronutrient deficiencies or frequent illness may
require a higher intake, above maintenance levels, in
order to correct deficiencies and recover from illness7.
And, finally, some minerals and vitamins are stored by
the body, whereas for others, when intake exceeds
needs, the excess is excreted rather than stored for
periods when needs exceed intake. For nutrients that
are not stored in the body, additional intake should be
on an ongoing basis.
Since it will often not be possible to get a good
estimate of the actual intake of specific micronutrients,
and because this differs widely among micronutrients,
among individuals, between seasons, and for other
reasons, proxy indicators can be used to determine
whether a population is likely to have micronutrient
deficiency problems. Such proxy indicators can include
the following: anemia prevalence (or, if available,
prevalence of iron deficiency), which is also an indicator
of micronutrient deficiencies more broadly; stunting
prevalence; frequent infections; night blindness
during previous pregnancy; lack of dietary diversity, in
particular the consumption of animal source foods and
fortified foods; inadequate nutrient density of typical
complementary foods (this is common when young
children eat from the family pot and do not receive
foods specially prepared for them); and food insecurity.
As the upper tolerable intake level (upper limit, UL)
for most micronutrients is well above the RNI, it is
considered safe to consume an additional full RNI (as
specified for the specific target group), i.e. one individual
dose, every day (for more details, see Q&A section
below)8. Therefore, the needs of the beneficiaries with
the lowest intake should guide the decision on how
many sachets to give for a period of time.
A target of, for example, 90 sachets per six months
period, i.e. 180 sachets per year, can be distributed at
different frequencies (e.g. 90 at once every six months,
30 every other month, 60 every four months). The
choice should be guided by programmatic feasibility,
such as integration with twice yearly high-dose vitamin
A capsule distribution, or monthly growth monitoring.
It is important to note that more frequent contact with
beneficiaries increases understanding and acceptance
(see section on behaviour change communication
below), but such contacts do not necessarily have to
be linked to the actual distribution of the MNP.
The message that is given about frequency of
consumption can also vary. For example, in the case of
90 sachets every six months, the instruction can be to
consume 3-4 per week and no more than one per day,
or specific days of the week can be designated to be
‘MNP consumption days’.
Furthermore, to spend resources most effectively, it is
important to give priority to those individuals with the
highest needs (i.e. at the greatest risk of micronutrient
deficiencies). This can, for example, be done through
geographic targeting to areas with the highest
prevalence of anemia or stunting or the greatest food
insecurity, or by linking the distribution, of MNP for
young children to a social safety net program that
targets the poorest. In this context, for those that are
not targeted by the social safety net program but are
also at risk of micronutrient deficiencies, MNP could be
available through sales at a subsidized or commercial
price. This combination of distribution strategies will
reduce the burden on public delivery systems, while
generating volumes of demand that can bring down
the price of MNP for all.
In conclusion: Sachets should be made available
throughout the year for the target groups, and should
be no less than 60 / 6 months and no more than 180 /
6 months (no more than one sachet per day). A target
of 90 sachets per six months period (equivalent to 15
per month, or 3-4 per week), which thus provides an
additional intake of 50% RNI/d for each micronutrient,
is likely to be reasonable for most situations.
Ultimately, the decision on which groups to target
with how many sachets, over what period of time, and
using which distribution strategies, should be based
on the risk of micronutrient deficiencies, estimated
micronutrient needs and available funds.
With regard to cost, even though product costs would
increase with the provision of more sachets (e.g. by
50% when providing 90 instead of 60 sachets per six
months period), it is important to note that the other
program costs do not increase much when the number of
35
distribution contacts
is the
Formulation
of MNP
same, and that training,
promotion and program monitoring and evaluation are
unchanged.most countries use an MNP formulation
Currently,
containing 15 micronutrients, which is designed to
provide one Recommended Nutrient Intake (RNI)
Key program components
of each micronutrient per dose for children 6-59
months old (see Table 1)5. WFP and UNICEF, as the
Any program requires inputs, so that the activities
main procurers of MNP, almost exclusively procure
needed to produce the expected outputs and outcomes
the 15 micronutrient formulation. However, where
can be implemented. For home food fortification with
specific information is available that warrants
MNP, the following program components need to be
adjusting the formulation, this could be done.
in place: policies, packaging/labelling, production
and/or supply, delivery system, quality control and
Target
behaviourgroups
change communication/demand creation.
The expected coverage (reaching all eligible children)
and adherence
(using
the MNP
as promoted,
by
The
target group
should
be those
who are e.g.,
at risk
adding
to foods
just before intake
consumption,
appropriate
of
having
an inadequate
of micronutrients;
frequency from
of use)
will be countries
achieved ifsuggests
effective activities
evidence
multiple
that the
are implemented
in each of these
period
of highest vulnerability
is sixcomponents.
to 23 months of age
when food variety and quantity are limited. Children
These
aspects
areof discussed
in detail
the risk
Home
24
to 59
months
age may also
be atinhigh
of
Fortification
Manual
of
the
Home
Fortification
Technical
inadequate dietary intake of some nutrients. When
Advisory
Group, which
willintroduced
come out in
but some
home
fortification
is being
in 2012,
a population
for
specific
aspects,
as
well
as
Q&A
for
frequently
asked
a period of several years, children aged 24-59 months
questions,
are described
below.
will
have been
exposed to
MNP when they were 6-23
months of age. In that case, prioritizing the age range
of 6-23 months may be a good choice. However, when
Delivery system
the problem of micronutrient deficiencies is widespread,
or the program will be implemented for a limited period
It is also important to note that home fortification is
of time, it might be better to target a wider age range.
best introduced as part of an infant and young child
feeding strategy, because the primary aim is to imAnother
target group
MNP
can be school foods
children,
prove nutrient
intake for
from
complementary
by
in
particular
those
who receive
school
meals
have
children
as of
six months
of age.
Thus,
by that
providing
limited
content
because breastfeeding
they consist
guidancemicronutrient
and counselling
on exclusive
largely
of
staple
foods,
and
protein
and
fat
The
for the first six months of life, andsources.
continued
micronutrient
content
of
MNP
for
school
feeding
should
breastfeeding thereafter, together with complementary
be
age group
appropriate.
experience
feeding
combined
with Preliminary
MNP, messages
are from
best
WFP
with
adding
MNP
to
school
meals
by
kitchen
coordinated. Providing MNP can be an incentive
to
staff
it is easy
to implement
and acceptance
comeistothat
information
sessions
about infant
and young
by
pupils
and staff
good.
Sachets
of MNP
usedwith
for
child
feeding.
For is
this
reason,
contact
points
school
feeding
10 or 20 dosages,
the health
care typically
sector orcontain
community-based
services
which
are
cheaper
per
dosage
compared
to
that bring caretakers together to discuss sachets
health,
containing
oneand
dose,
due to lower feeding
packaging
costs.
breastfeeding
complementary
of young
children are more appropriate channels for distribution
If
thedissemination
micronutrientabout
intake
pregnant
andincreasing
information
MNPofthan
other
and
lactating
women
thisdomay
be
points
of contact
with isthedesirable,
family that
not best
include
done
in
the
form
of
a
capsule,
rather
than
as
MNP,
this focus, for example, the distribution of food rations
because
the relatively
high dose of micronutrients
or cash transfers
for families.
Behaviour change communication (BCC)
TABLE 1. RECOMMENDED NUTRIENT INTAKE (RNI) OF
EACH MICRONUTRIENT PER DOSE FOR CHILDREN 6-59
As with any new product, a number of barriers may
MONTHS OLD
exist to its acceptance and utilization by the target
Micronutrients
Children (6-59 months)
population.
This may be particularly
true for child
RE and traditions 400
feeding,Vitamin
whereA µg
habits
may strongly
dictate what
is
acceptable
and
appropriate
Vitamin D µg
5to provide to
small children. The regular and appropriate utilization
Vitamin
E mgfor their children requires
5
of MNP by
families
them to
be knowledgeable
about why they should
Vitamin C mg
30 do so and
that they know how to use the product. It also must be
Thiamine (vitamin B1) mg
0.5
clear for whom in the family the MNP is intended, and
Riboflavin
(vitamin
B2) mg to use it.
0.5
families
must
be motivated
Niacin (vitamin B3) mg
6
Successful communication requires the development
B6 (pyridoxine)
0.5
of Vitamin
a strategy
intended mg
to change behaviour
related
toVitamin
child B12
feeding
in the target
population
(cobalamine)
µg
0.9 that takes
into account factors
that might impede or facilitate
Folate µg6
150.0
appropriate utilization (i.e., local contextual and
Iron mg
10.0 be taken
cultural knowledge).
This knowledge should
into consideration
Zinc mg in all aspects of program
4.1 design and
implementation, including the local name selected for
Copper mg
the product
and package specifications,0.56
selection and
Selenium
µg will be responsible17.0
training of
those who
for delivery of
the MNP and
any promotional
materials that
will be used.
Iodine
µg
90.0
Experience suggests that utilization of the principles
that
is required
is more
likely to change
the taste of
of social
marketing
can increase
the effectiveness
the
that it isThe
added
and limited
programming
BCCfood
campaigns.
BCC to,
campaign
should
ensure that
experience
shows arethat
women
mayaccessible
prefer
information sources
available
and easily
so that questions
and concerns
to MNP
can be
swallowing
a capsule
instead related
of adding
something
easily
addressed.
marketing,
to
their
food. ThePublic
samemessaging,
may applysocial
to adolescents.
and where relevant, commercial marketing should
be harmonised to ensure that beneficiaries of MNP
Frequency
and duration of taking MNP
programs are not confused.
In
principle,
the frequency
and important,
duration ofsousing
Training
the media
is also very
that MNP
they
should
be
such
that
it
contributes
enough
of
know what MNP is, who should use it, how itrequired
should
micronutrients
so that
the combination
the they
diet and
be used and other
aspects
of MNP, soofthat
can
the
meets the
(i.e. the
dailyand
recommended
writeMNP
informative
andRNI
accurate
articles
support the
nutrient
for campaign.
all micronutrients. When the
messagesintake)
of the BCC
sachets contain one RNI for each micronutrient,
giving 90 sachets for a six month period (providing
Monitoring
evaluation
on
average 15 and
per month,
i.e. 3-4 per week) would
result in an average dose of 50% of the RNI/d, 60
It is important, to assess provision, coverage, and
sachets for a six month period (10 per month, i.e. 2-3
adherence, changes of Infant and Young Child Feeding
per week) would be equivalent to 33% of the RNI/d,
(IYCF) practices and impact on micronutrient intake
and 120 sachets for a six month period (20 per month,
(dietary diversity and MNP), status and function.
i.e. 4-5 per week) would provide 67% of RNI/d.
Information on provision, coverage, and adherence
6
PROGRAMMATIC GUIDANCE BRIEF ON USE OF MICRONUTRIENT POWDERS
(MNP) FOR HOME FORTIFICATION
should be collected regularly and, in particular,
simultaneously with program initiation so that any
issues that arise can be tackled immediately. Issues
related to successful implementation, coverage and
adherence should be resolved before assessing program effectiveness, i.e. before evaluating impact on
biological outcomes such as micronutrient status, and
morbidity. The issues identified, as well as how they
have been addressed, need to be well documented.
The objectives for implementing a home fortification
program should be clearly stated and program
appropriate targets, consistent with program design,
should be specified before implementation. Program
monitoring and evaluation should be designed to
ensure that key information that is collected to assess
whether these targets are being met is included in a
timely fashion.
Questions and Answers
1. Can MNP be provided in combination with other fortified products and supplements, such as
a.
b.
c.
d.
High-dose vitamin A capsules (VAC)
Iodized salt
General food fortification of flour, oil, salt etc
Specially formulated products (LNS, RUTF, CSB+/++,
WSB+/++, RUSF etc)
MNP can be safely provided in addition to twice-yearly
high-dose VAC9, iodized salt and general food fortification.
Combining it with other specially formulated products, such as RUTF
(ready-to-use therapeutic food) for treatment of SAM (severe acute
malnutrition), RUSF (ready-to-use supplementary food) or fortified
blended foods such as WSB++ (wheat-soy blend) or CSB++ (cornsoy blend) for treatment of MAM (moderate acute malnutrition), or
small-quantity LNS (lipid-based nutrient supplement, ≤= 20 g/d,
providing ≤=120 kcal/d) is not appropriate, because those products already contain a similar or higher amount of micronutrients.
In this case, one can recommend keeping the MNP for later, when
the other products are no longer used.
2. Can the same amount of one sachet/d with the 15 micronutrient
formulation be used by all 6-59 month old children, or should
younger children use smaller portions?
All children, as of six months of age, can consume the full sachet
once per day, because the RNI is actually designed to provide one
RNI for children 6-59 months old5.
3. Is it harmful when some children reach an intake above the
Tolerable Upper Limit (UL) from the combination of the diet and the
MNP for one or more micronutrients?
The Tolerable Upper Limit (UL) is the highest level of daily nutrient
intake that is likely to pose no risk of adverse health effects to
almost all individuals (97.5%) in the general population and applies
to daily use for a prolonged period of time10.
Furthermore, it is important to note the following about the UL:
• The UL is well above the RNI for most nutrients in the MNP
• It is not the level at which adverse effects have been
observed – it includes a safety margin and is conservative
• The adverse effects that have been considered for setting
the UL are associated with chronic intake, rather than with
acute toxicity which occurs at much higher intake levels
• Where nutrient-nutrient interactions determined the UL (such as a higher zinc intake affecting copper status, or higher
folic acid intake affecting vitamin B12 status), a concurrent
increase of the intake of both micronutrients involved would
allow a higher intake.
• The UL applies to normal, healthy individuals with adequate
stores and no deficits to be corrected
• Recommended nutrient intakes for treatment of severe and
moderate acute malnutrition exceed the UL for 3 nutrients
that are also included in MNP (zinc, vitamin A, folic acid), which
is considered safe and necessary for treatment7.
Thus, there is no immediate safety risk when an individual’s intake
occasionally exceeds the UL. Furthermore, consuming more than
the UL is very unlikely to occur for most micronutrients.
4. Have adverse events been reported from the use of MNP?
Diarrhea is sometimes reported by caretakers when children start
using MNP, usually by <1% of the population. Whether this is related
to the MNP itself is not known. When a new product or treatment
is introduced, consumers may ascribe any health problems that
concurrently arise to the product or treatment. Communications
messages when introducing the MNP should say that mild diarrhea
may occur but one should not worry, that it should be treated as
usual with increased liquids, and that MNP consumption does not
need to be interrupted. When the diarrhea is severe, or is bloody or
with mucus, care should be sought as it would have been without
concurrent use of MNP.
5. Can MNP be used in malarial areas?
In malaria-endemic areas, the provision of iron-containing MNP
should be implemented in conjunction with measures to prevent,
diagnose and treat malaria11. WHO will soon publish a specific
guideline on the use of iron in malaria-endemic areas.
37
Formulation of MNP
TABLE 1. RECOMMENDED NUTRIENT INTAKE (RNI) OF
EACH MICRONUTRIENT PER DOSE FOR CHILDREN 6-59
MONTHS OLD
Micronutrients
Children (6-59 months)
Currently, most countries use an MNP formulation
containing
15 References
micronutrients, which is designed to
Notes and
provide one Recommended Nutrient Intake (RNI)
of1 each micronutrient per dose for children 6-59
Vitamin A µg RE
400
Note that children should be exclusively breastfed until six months of age and should be introduced
months old (see Table 1)5. WFP and UNICEF, as the
Vitamin D µg
5
to complementary
food
at sixexclusively
months of procure
age.
main
procurers of MNP,
almost
2
Vitamin
mg
5
Guideline: Use
of multipleHowever,
micronutrient
homeE fortification
of foods consumed
theWHO.
15 micronutrient
formulation.
wherepowders for
by
infants
and
children
6–23
months
of
age.
Geneva,
World
Health
Organization,
2011.
specific information is available that warrants
Vitamin C mg
30
3
De-Regilthe
LM,formulation,
Suchdev PS, this
Vist GE,
S, Peña-Rosas JP. Home fortification of foods
adjusting
couldWalleser
be done.
Thiamine (vitamin B1) mg
0.5
with multiple micronutrient powders for health and nutrition in children under two years of
Riboflavin (vitamin B2) mg
0.5
age. Cochrane
Target
groups Database of Systematic Reviews 2011, Issue 9. Art. No.: CD008959. DOI:
Niacin (vitamin B3) mg
6
0.1002/14651858.CD008959.pub2
4
Pee S,group
Kraemer
K, van
den Briel
et al.
criteria
for(pyridoxine)
micronutrient
TheDetarget
should
be those
who Tare
at Quality
risk
Vitamin B6
mg powder products:
0.5
report
of
a
meeting
organized
by
the
World
Food
Programme
and
Sprinkles
Global Health Initiative.
of having an inadequate intake of micronutrients;
Vitamin B12 (cobalamine) µg
0.9
Food Nutr
2008;countries
29: 232-41.
evidence
fromBull
multiple
suggests that the
6
5
Folate µg
150.0
period
of highest
vulnerability
is six
to 23 months
of age and controlling
WHO,
WFP, UNICEF:
Joint
statement.
Preventing
micronutrient deficiencies
when
food variety affected
and quantity
areemergency
limited. Children
Iron mg
10.0
in populations
by an
(2007). http://www.who.int/nutrition/publications/
24 micronutrients/WHO_WFP_UNICEFstatement.pdf
to 59 months of age may also be at high risk of
Zinc mg
4.1
6
inadequate
dietary
intake of some
When
150 μg folate
is equivalent
to 88nutrients.
μg folic acid.
Copper mg
0.56
home
fortification
is being introduced
in a population
7
Golden
MH. Proposed
recommended
nutrientfor
densities for moderately malnourished children. Food
a period of several years, children aged 24-59 months
Selenium µg
17.0
Nutr Bull 2009; 30: S267-342.
will
have
been
exposed
to
MNP
when
they
were
6-23
8
µg
90.0
Micronutrient supplements that are sold over-the-counter inIodine
developed
countries and to
the
months of age. In that case, prioritizing the age range
upper
market
segment
in
developing
countries
usually
contain
1
RNI
of
each
nutrient,
and
of 6-23 months may be a good choice. However, when that is required is more likely to change the the
taste of
intake ofdeficiencies
these supplements
is usually
daily.that it is added to, and limited programming
therecommended
problem of micronutrient
is widespread,
the
food
9
Kraemer
K, will
Waelti
M, de Pee Sfor
et aal.
Are low
tolerable
upper intake
or the
program
be implemented
limited
period
experience
showslevels
thatfor vitamin
women A may prefer
undermining
effective
food
fortification
efforts?
Rev 2008;
66: 517-25.
of time,
it might be
better to
target
a wider age
range. Nutr
swallowing
a capsule
instead of adding something
10
Food and Nutrition Board, Institute of Medicine. 1998.
Dietary
Reference
A Risk
to their food. The same Intakes:
may apply
to adolescents.
Another
target
group
for
MNP
can
be
school
children,
Assessment Model for Establishing Upper Intake Levels for Nutrients.
in11particular
those who
receive
school meals
that havepowders for home fortification of foods consumed
WHO. Guideline:
Use
of multiple
micronutrient
Frequency and duration of taking MNP
limited
micronutrient
content
because
they
consist
by infants and children 6–23 months of age.
Geneva, World Health Organization, 2011
largely of staple foods, and protein and fat sources. The
micronutrient content of MNP for school feeding should In principle, the frequency and duration of using MNP
be age group appropriate. Preliminary experience from should be such that it contributes enough of required
WFP
with adding MNP to school meals by kitchen micronutrients so that the combination of the diet and
Acknowledgements
staff is that it is easy to implement and acceptance the MNP meets the RNI (i.e. the daily recommended
by pupils and staff is good. Sachets of MNP used for nutrient intake) for all micronutrients. When the
The following individuals contributed to this note: Saskia de Pee, Arnold Timmer, Elviyanti Martini,
school feeding typically contain 10 or 20 dosages, sachets contain one RNI for each micronutrient,
Lynnette Neufeld, Joris van Hees, Dominic Schofield, Sandy Huffman, Jonathan Siekmann, Klaus
which are cheaper per dosage compared to sachets giving 90 sachets for a six month period (providing
Kraemer, Stanley
Zlotkin,
Akoto
Osei
and Kaycosts.
Dewey.on average 15 per month, i.e. 3-4 per week) would
containing
one dose,
due to
lower
packaging
result in an average dose of 50% of the RNI/d, 60
If increasing the micronutrient intake of pregnant sachets for a six month period (10 per month, i.e. 2-3
and lactating women is desirable, this may best be per week) would be equivalent to 33% of the RNI/d,
done in the form of a capsule, rather than as MNP, and 120 sachets for a six month period (20 per month,
because the relatively high dose of micronutrients i.e. 4-5 per week) would provide 67% of RNI/d.
HF-TAG
The Home Fortification Technical Advisory Group (HF-TAG) is a community of stakeholders involved in home
fortification, comprised of members from the public, private, academic and non-governmental organization sectors.
The initiative aims to build technical consensus on issues related to home fortification and to provide guidance
on standards, guidelines and other resources to policymakers, non-governmental organizations, international
organizations, corporations (manufacturers and suppliers), innovators/social entrepreneurs, academia and
media. The group’s mission is to facilitate implementation of well-designed and effective home fortification
projects at scale, based on sound technical guidance and best practices, integrated into comprehensive nutrition
strategies for children. Its vision is of a world without malnourished children.
Partners involved in the production of this document
Centers for Disease Control and Prevention
Global Alliance for Improved Nutrition
Helen Keller International
Micronutrient Initiative
Sight and Life
Sprinkles Global Health Initiative
UC DAVIS
UNICEF
World Food Programme